Project Summary/Abstract Assisted living (AL) communities in the U.S. were largely designed to fill the gap between independent living and nursing home by providing housing and support services. The acuity of persons living in AL has increased over the last two decades, and today more than 50% of AL residents require supportive care such as help with medications and assistance in activities of daily living (ADLs), 40% have moderate to severe dementia, and 90% some degree of cognitive impairment. The rapid growth of AL communities has occurred largely without federal financing or oversight and with variable state regulatory efforts and stringency. Consequently, relatively little is known about the safety culture of the AL environment and its impact on residents' safety and health outcomes. The 1999 Institute of Medicine (IOM) report ?To Err is Human? prompted many healthcare organizations to focus on ?patient safety culture? and the need to organize their care processes so as to minimize care delivery errors and improve the provision of patient care. In the last decade, significant progress to improve safety culture (e.g. teamwork, management support for patient safety) in acute care hospitals, and to some extent in nursing homes, has been made and the literature shows that improved safety culture is associated with better patient outcomes. By comparison AL communities, which are state-regulated, receive no or little scrutiny from federal policy makers, the state oversight of these organizations vary widely, and even less is known about their safety culture. AL communities have substantially fewer reporting requirements than nursing homes yet to a large extent serve residents with similar care needs. It is not known if and to what extent the stringency of state AL regulations impacts the development of safety culture practices in this care setting, and how both of these forces influence residents' outcomes. To address these significant gaps in knowledge our proposed project will examine the variation in AL patient safety culture, its relationship to residents' health outcomes, and the potential impact of state regulations on safety culture and outcomes. We propose to survey administrators and direct care workers in a large, nationally representative sample of ALs using an adapted version of the AHRQ patient safety survey instrument. We will employ existing databases of state ALR regulations and policies. We will use Medicare administrative and claims data to identify AL residents and to define risk-adjusted outcomes. We will also employ public use data to define other needed covariates. These data will be used to construct AL patient safety culture measures, measures of state stringency, measures of residents' risk-adjusted outcomes, and facility, market and state covariates. Hypotheses will be tested using multivariable regressions. The information generated through this study will increase knowledge of AL communities and their ability to adequately and safely serve their residents. The project will provide the much-needed evidence for the design of future practice and policy initiatives aimed at improving patient safety and care quality in AL.